Prevalence of vitamin D deficiency in critically-ill COVID-19 patients

The role of vitamin D in supporting the body’s immune response to respiratory viruses has become a topic of significant interest during the COVID-19 pandemic, especially for critically-ill patients with severe respiratory failure. We therefore were interested in examining the prevalence of vitamin D deficiency in adult patients admitted to our critical care unit due to COVID-19 infection during the second surge of the virus in the UK. Due to vitamin D being a negative acute phase reactant and serum concentration falling in the presence of a systemic inflammatory response, and following local multidisciplinary discussion involving a Consultant Biochemist, a pragmatic recommendation was made to consider assessing for vitamin D deficiency in patients with (a) a deranged serum adjusted calcium, phosphate or alkaline phosphatase, or (b) evidence of vitamin D supplementation prior to hospital admission. Retrospective data was examined for 168 patients admitted to critical care from 04.10.20 to 04.04.21 and analysed using an excel spreadsheet. Local diagnostic cut-off values determined if serum vitamin D level was deficient, suboptimal or adequate. Table 1 below summarises the results for 33/168 patients (19.6%) who had a serum vitamin D result available. [Formula presented] Acknowledging the small number of tests within our patient population, our results demonstrate a high prevalence of patients (>50%) with a vitamin D level indicative of deficiency. If combined with those with suboptimal levels, this increases further to 75.8%. Interestingly, of the 134 patients (80.4%) with no serum vitamin D result, there was a high prevalence of recognised risk factors for deficiency such as age, presence of obesity and non-white ethnicity. It is also key to consider the impact of reduced sunlight exposure due to seasonality and COVID-19 lockdown restrictions on the vitamin D status of the whole UK population, which led to reissued government guidance1,2 that more people should consider taking a daily vitamin D supplement. Recent clinical guidance identifies that at present, there is little evidence available for vitamin D for preventing or treating COVID-19 but it acknowledges that a low vitamin D status is associated with more severe clinical outcomes3. We support the recommendation that further research is required in this area, including patient outcomes, and if routine vitamin D supplementation could benefit critically-ill COVID-19 patients. References 1. Vitamin D, National Health Service (NHS), 2020. (Accessed June 21, 2021 at ) 2. Scientific Advisory Committee on Nutrition (SACN) Rapid review on vitamin D and acute respiratory tract infections (ARTI), 2020. (Accessed June 21, 2021 at ) 3. National Institute for Health and Care Excellence (NICE) COVID-19 rapid guideline: vitamin D [NG187], 2020 (Accessed June 21, 2021 at )

Nutritional comparison of surge one and surge two COVID-19 patients in an adult intensive care unit

It has been a hugely challenging task proving nutritional support in adult intensive care units during the COVID-19 pandemic. We therefore reviewed the nutritional parameters of patients admitted to intensive care during both surges of the virus to provide detailed information and to ensure we are fully informed to provide the best service in future surges. Retrospective data was collected from 168 patients using dietetic electronic handovers from 04.10.20 to 04.04.21 and compared to the data collected for 122 patients in surge one, (data collected 20.03.20 to 8.5.20). This was analysed using an excel spreadsheet. The results are outlined in table one below: [Formula presented] The critical care ventilation plan for these patients had been reviewed1 and this impacted the route of feeding as follows: Nasogastric feeding on admission: 50.6% (96%), oral nutritional support: 35% (4%), oral nutritional support with subsequent NG feeding: 11% (3%), parenteral nutrition: 1.8% (0), PEG: 0.62% (0). Using data collected from surge one, we were able to prepare training for the dietetic team with regards to the demographics of the patient and the impact on nutritional care. This is particularly important with regards to the challenge of meeting energy and protein requirements of obese patients2. We reviewed the difficulties gathering accurate weights from the first wave and purchased new patient transfer scales®. This allowed us to gain weights that we would not have been able to. More patient heights were available as dietitians were present on the unit in surge two (remote working in surge one) and were able to do bedside measures of ulna length where a height was unavailable. Using surge one data we were prepared for high numbers of patients requiring enteral feeding on admission. However there was a different picture in surge two with more patients awake, using high flow oxygen therapy or on a CPAP hood. This brought different challenges with meeting macro and micronutrients orally. Patients with breathing difficulties were not keen to consent to an NGT and when they did, the NGT insertion procedure was tricky in those patients with high Fi02. We reviewed our range of macronutrient supplements and started using an oral protein supplement containing 30 mls, 10 g protein and 100 kcal to help with this. We attended MDT meetings to discuss feeding route and for further surges we plan to implement a standard operating procedure for enteral feeding patients on CPAP. 1. Intensive Care Society (2021) Clinical Guideline for the management and care of critically ill adults with COVID-19 during the coronavirus pandemic. Faculty of Intensive care Medicine. 2. Singer et al (2019) ESPEN guideline on clinical nutrition in the intensive care unit: Clinical Nutrition 38:48-79

POSA326 Cross-Border Collaboration to Support Pricing and Access for High-Cost, High-Value Therapies: A Review of Initiatives within Europe

Objectives: Cross-border collaboration for the evaluation and procurement of medicines can be undertaken to pool expertise, minimise risk and increase bargaining power. This has become increasingly important in Europe to improve affordability and access to innovative therapies in areas of high-unmet need. This research aims to understand the rationale for collaboration across borders, outcomes of joint initiatives (and associated implications) and key success factors. Methods: A comprehensive review of cross-country collaborations was conducted with a focus on HTA, pricing, procurement, and patient management. Established collaboration models were prioritised including the Valetta Declaration, BeNeLuxA initiative, Nordic Pharmaceutical Forum, and FiNoSe. EU COVID-19 pricing and procurement agreements and cross-border healthcare initiatives in response to the pandemic were also reviewed. Results: Successful collaborations occur primarily at the HTA level to pool expertise for evaluation of high-cost, high-value therapies (e.g., Zolgensma by BeNeLuxA and Zynteglo by FiNoSe), however to date influence on access and reimbursement has been minimal. Furthermore, cross border collaboration for price negotiations have had limited success. Successful implementation requires alignment regarding processes and priorities between countries and active engagement from both payers and manufacturers;in this context smaller initiatives with fewer countries are more likely to achieve cross-market consensus. Conclusions: Collaborations are occurring more frequently to support evaluation of high-cost, high-value therapies and to provide a solution for emergency medical care where capacity in individual countries or regions is limited. With an increasing number of innovative therapies in late-stage clinical development, and support for voluntary member state collaborations at the European level, such initiatives are likely to increase in future to pool resources and address shared health priorities across markets. Increased collaboration may lead to further consolidation of evaluation frameworks for high-cost, high-value therapies, including the associated management of clinical and financial uncertainty (e.g., recently introduced EU joint HTA).

Veno-venous extracorporeal membrane oxygenation (v-v ecmo) as a bridge to lung transplantation following severe COVID-19 infection

Introduction The Coronavirus Disease 2019 (COVID-19) has proven to be the most infectious and deadly respiratory virus since the 1918 H1N1 influenza A pandemic. According to the World Health Organization (WHO), COVID-19 has caused over 62 million infections and more than 1.4 million deaths worldwide in the first year of the pandemic. This case report depicts the clinical course of a patient with severe acute respiratory distress syndrome (ARDS) caused by COVID-19, requiring VV-ECMO and bilateral orthotopic lung transplantation (BOLT). Case Description R.R. was a 57-year-old triathlete with history of smoking 20 years ago, anxiety, and depression. He initially presented to an outside hospital (OSH) with symptoms of fever and dyspnea and was admitted to the intensive care unit (ICU) due to increasing oxygen requirements on BiPAP seven days later. Notably, two subsequent COVID tests resulted negative. On hospital day (HOD) 28, he necessitated urgent cannulation for VV-ECMO and was transferred to our institution for further management. R.R.'s ICU course was characterized by a progressive decline of respiratory function. Chest computed tomography (CT) revealed severe bullous emphysema and interstitial fibrosis. The patient developed right ventricular (RV) failure warranting treatment with inhaled nitric oxide and diuresis. Given the overall clinical status, he underwent expedited work-up and listing for lung transplantation. On HOD 32 he required intubation for worsening hypoxemia despite ECMO support with flows of 4.5 L/min, sweep of 4 L/min and circuit FiO2 of 100% with maximum lung protective ventilator support. Notably, a repeat COVID test was positive. Several days later, he underwent a tracheostomy. He continued to experience refractory hypoxia and hypercarbia, necessitating deep sedation, paralysis, and ECMO sweep of 14 L/min on the night preceding his BOLT. Post-operative course was largely unremarkable. His tracheostomy was decannulated on HOD 52 and he was discharged to rehab on HOD 59. The patient spent 17 days in rehab and was discharged home. Discussion In this case, an active triathlete without significant comorbidities developed severe pulmonary fibrosis leading to end stage lung disease from COVID-19. The vast majority of patients infected with COVID-19 have mild to moderate disease. However, patients with severe disease requiring mechanical ventilation have a mortality rate of up to 20-25%. The proportion of patients who require ECMO and lung transplantation is small. This case illustrates the merit of urgent evaluation for ECMO candidacy and consideration of lung transplantation for selected individuals in this small cohort of patients.